UNDERSTANDING THE U.S. HEALTH SERVICES

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1 UNDERSTANDING THE U.S. HEALTH SERVICES SYSTEM Fourth Edition

2 AUPHA/HAP Editorial Board for Graduate Studies Timothy D. McBride, PhD, Chair Washington University in St. Louis John Baker, PhD University of Arkansas for Medical Sciences Simone Cummings, PhD Washington University Connie J. Evashwick, ScD, FACHE St. Louis University Sherril B. Gelmon, DrPH, FACHE Portland State University Thomas E. Getzen, PhD Temple University Diane M. Howard, PhD, FACHE Rush University Christy H. Lemak, PhD University of Michigan John M. Lowe III, PhD Simmons College Lydia Middleton AUPHA Dawn Oetjen, PhD University of Central Florida Mark Pauly, PhD University of Pennsylvania Bernardo Ramirez, MD University of Central Florida Andrew T. Sumner, ScD Georgia State University Andrea W. White, PhD Medical University of South Carolina Lesly Wilson, PhD University of South Carolina

3 UNDERSTANDING THE U.S. HEALTH SERVICES SYSTEM Fourth Edition Phoebe Lindsey Barton Health Administration Press, Chicago, Illinois AUPHA Press, Washington, DC

4 Your board, staff, or clients may also benefit from this book s insight. For more information on quantity discounts, contact the Health Administration Press Marketing Manager at (312) This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The statements and opinions contained in this book are strictly those of the author and do not represent the official positions of the American College of Healthcare Executives, the Foundation of the American College of Healthcare Executives, or the Association of University Programs in Health Administration. Copyright 2010 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher Library of Congress Cataloging-in-Publication Data Barton, Phoebe Lindsey. Understanding the U.S. health services system / Phoebe Lindsey Barton. 4th ed. p. ; cm. Includes bibliographical references and index. ISBN (alk. paper) 1. Medical care United States. 2. Medical policy United States. 3. Medical economics United States. I. Title. [DNLM: 1. Health Services United States. 2. Delivery of Health Care United States. 3. Economics, Medical United States. 4. Health Policy United States. W 84 AA1 B293u 2010] RA395.A3B dc The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences Permanence of Paper for Printed Library Materials, ANSI Z Acquisitions editor: Janet Davis; Project manager: Eduard B. Avis; Cover designer: Trisha Lartz. Take Cover Design; Layout: BookComp Found an error or typo? We want to know! Please it to and put Book Error in the subject line. For photocopying and copyright information, please contact Copyright Clearance Center at or at (978) Health Administration Press Association of University Programs A division of the Foundation in Health Administration of the American College of 2000 North 14th Street Healthcare Executives Suite 780 One North Franklin Street, Arlington, VA Suite 1700 (703) Chicago, IL (312)

5 In loving memory of Doctors Milton and Ruth Roemer and their seminal work on health care systems.

6

7 brief Contents List of Acronyms and Abbreviations.... xxi Preface... xxix Part I Introduction 1 Introduction to the U.S. Health Services System An Overview of the U.S. Health Services System and Its Users Access to Health Services Part II System Organization 4 Organization of the U.S. Health Services System...77 Part III System Management 5 Management of the U.S. Health Services System...97 Part IV Economic Support 6 Health Insurance: The Major Financing Mechanism for the U.S. Health Services System Financing the U.S. Health Services System Part V Resource Production 8 The Health Services Workforce Hospitals Biomedical Research, Health Services Technology, and Technology Assessment vii

8 viii Brief Contents Part VI The Delivery System 11 Overview of the U.S. Health Services Delivery System Health Promotion and Disease Prevention Primary Care Secondary Care Long-Term Care Tertiary Care Palliative Care The Care of Special Populations and Special Disorders The Health Services Delivery System: How Managed Care Has Influenced Delivery Part VII Measuring Outcomes of the Delivery System 20 Issues in Quality of Care Epilogue Glossary of Key Words Bibliography Index About the Author

9 Contents List of Acronyms and Abbreviations.... xxi Preface... xxix Part I Introduction 1 Introduction to the U.S. Health Services System...3 Exhibit 1.1 Types of National Health Systems...4 Overview of the U.S. Health Services System Exhibit 1.2 Continuum of Health Services...5 The Roemer Model of a Health Services System....5 Exhibit 1.3 National Health System: Components, Functions, and Their Interdependence... 6 Organization of Health Services....6 Management of a Health Services System....7 Production of Health Services Resources...8 Delivery of Health Services...8 System Values: Access, Cost and Expenditures, and Quality... 8 Organization of the Book...9 Data on U.S. Health Services Aids to Understanding the Complexity of the U.S. Health Services System An Overview of the U.S. Health Services System and its Users...11 An Overview of the U.S. Health Services System Distinguishing Health from Illness and Disease...15 Exhibit 2.1 Determinants of Health Exhibit 2.2 U.S. Crude Birthrates and Fertility Rates Exhibit 2.3 U.S. Life Expectancy at Birth, Age 65, and Age Exhibit 2.4 U.S. Low-Birth-Weight (<2,500 grams) Babies Exhibit 2.5 U.S. Very-Low-Birth-Weight (<1,500 grams) Babies Exhibit 2.6 Limitations Caused by Chronic Conditions...20 ix

10 x Contents Exhibit 2.7 U.S. Infant Mortality Rates, Fetal Death Rates, and Perinatal Mortality Rates...21 Exhibit 2.8 Leading Causes of Death, All Races and Both Genders, U.S. Rank Order and Number of Deaths...22 U.S. Health Status Compared with Other Industrialized Countries...22 Exhibit 2.9 Leading Causes of Death for U.S. Males...23 Exhibit 2.10 Leading Causes of Death for U.S. Females Exhibit 2.11 U.S. Age-Adjusted Death Rates Exhibit 2.12 Health Outcome Measures in Select OECD Countries...26 Factors That Affect Care-Seeking Behavior...26 Exhibit 2.13 U.S. Respondent-Assessed Health Status Utilization of Health Services...27 Exhibit 2.14 U.S. Population by Gender Exhibit 2.15 U.S. Population by Age Group Exhibit 2.16 U.S. Population by Race Models of Health Services Utilization...30 Exhibit 2.17 Percentage of U.S. Persons and Families Below Poverty Level...31 Exhibit 2.18 Expanded Health Behavior Model Exhibit 2.19 Health Belief Model...33 Exhibit 2.20 Health Services Home Visits and Visits to Physicians Offices and Emergency Departments Within the Past 12 Months...34 Exhibit 2.21 U.S. Ambulatory Visits to Physicians Offices, Hospital Outpatient Departments, and Emergency Departments Exhibit 2.22 Health Services Home Visits and Visits to Physicians Offices and Emergency Departments Exhibit 2.23 Health Services Home Visits and Visits to Physicians Offices and Emergency Departments Within the Past 12 Months...36 Exhibit 2.24 Ambulatory Care Visits to Physicians Offices, Hospital Outpatient Departments, by Gender and Race Exhibit 2.25 Health Care Home Visits and Visits to Physicians Offices and Emergency Departments Within the Past 12 Months, by Health Insurance Status and Age...37 Exhibit 2.26 Discharges from U.S. Short-Stay Hospitals The Effects on Health Status of Receiving Health Services...38 Exhibit 2.27a U.S. Medicare Home Health Care Patients, According to Age and Gender Exhibit 2.27b Medicaid Home Health Care Patients, According to Medicaid Classification and Gender...39 Exhibit 2.28 U.S. Nursing Home Reisdents ate Exhibit 2.29 Prenatal Care for U.S. Live Births, by Race and Hispanic Origin of Mother, First Trimester Exhibit 2.30 Prenatal Care for U.S. Live Births, by Race and Hispanic Origin of Mother, Third Trimester

11 Contents xi 3 Access to Health Services Defining Access...45 Exhibit 3.1 Dimensions of Access to Health Services...46 Factors Affecting Access to Health Services...47 Exhibit 3.2 Factors Affecting Access to Health Services...48 Financial Access to Health Services...50 Exhibit 3.3 Private Health Insurance Among Persons <65 Years Old, Exhibit 3.4 Private Health Insurance Obtained Through the Workplace, <65 Years Old, Exhibit 3.5 Health Insurance Coverage, All Ages, Exhibit 3.6 Comparison of Medicare and Medicaid Programs...56 Exhibit 3.7 VA Expenditures for Health Care, Exhibit 3.8 Inmates in State or Federal Prisons and Local Jails by Gender, Race, and Ethnicity, Potential Adverse Outcomes Associated with Lack of Access or Unconstrained Access to Health Services Exhibit 3.9 Reduced Access to Medical Care During the Previous 12 Months Because of Cost, by Selected Characteristics, Access to Health Services for the Uninsured Exhibit 3.10 No Health Insurance Coverage Among Persons <65 Years, A Focus on Health Disparities...69 Exhibit 3.11 Summary of Agency for Healthcare Research and Quality s 2006 National Healthcare Disparities Report Part II System Organization 4 Organization of the U.S. Health Services System...77 Public Health Roles and Functions...77 Exhibit 4.1 The Roles of Public Health...78 Ministry of Health...79 Exhibit 4.2 U.S. Department of Health and Human Services Organization Chart...80 Exhibit 4.3 National Institutes of Health Quasi-Governmental Organizations...88 Voluntary Agencies in the U.S. Health Services System Enterprises in the U.S. Health Services System The Private Market in the U.S. Health Services System Part III System Management 5 Management of the U.S. Health Services System...97 Planning...97

12 xii Contents Administration Legislation Regulation Exhibit 5.1 Examples of U.S. Health Services Legislation Part IV Economic Support 6 Health Insurance: The Major Financing Mechanism for the U.S. Health Services System General Insurance Concepts Concepts Specific to Health Insurance Exhibit 6.1 Examples of Industries Ineligible for Health Insurance under Selected Insurer Plans Evolution of Health Insurance as the Primary Mechanism for Financing Health Services Exhibit 6.2 Percentage Distribution of U.S. Population, by Health Insurance Coverage, Exhibit 6.3 Percentage of U.S. Population Covered by Health Insurance, by Age and Type of Coverage (2006) Exhibit 6.4 Percentage of Workers Younger than 65 Years with Employer-Sponsored Health Insurance, Exhibit 6.5 Percentage of Establishments Offering Retiree Health Benefits, by Establishment Characteristics, 1997 and Exhibit 6.6 Increases in Health Insurance Premium Costs Exhibit 6.7 Average Percentage of Premium Paid by Employer, All Types of Plans, Exhibit 6.8 Americans with Private Health Coverage (State and Federal Authority to Regulate Sources of Private Coverage) Exhibit 6.9 Enrollment in Employer-Sponsored Health Plans by Type, Select Years Exhibit 6.10 Profile of Medicare Beneficiaries Exhibit 6.11 Comparison of Medicare Parts A (Health Insurance) and B (Supplementary Medical Insurance), Exhibit 6.12 Distribution of Medicare Program Payments, by Type of Service, Exhibit 6.13 Medicare Expenditures by Type of Expenditure and Type of Coverage, Exhibit 6.14 Medigap Benefits by Plan Type Exhibit 6.15 Groups Eligible for Medicaid Exhibit 6.16 Medicaid Optional Services Exhibit 6.17 Medicaid Enrollees, by Medicaid Category and Expenditures per Category,

13 Contents xiii Exhibit 6.18 Distribution of Medicaid Payments by Type of Service (2005) Exhibit 6.19 Workers Compensation Public Fund Expenditures for Personal Health Care, Exhibit 6.20 Number of Uninsured Under Age 65, in Millions, for Select Years Between 1984 and Regulation of Health Insurance Exhibit 6.21 Number of States with Specific Mandates for Health Insurance Policies, Proposed Changes in the U.S. Health Insurance Industry Appendix Appendix Financing the U.S. Health Services System How Health Services are Financed Exhibit 7.1 Major Events in Financing U.S. Health Services Exhibit 7.2 Sources of Funds (Revenue) That Finance U.S. Health Services, Exhibit 7.3 Percentage of Public- and Private-Sector Sources of Financing, U.S. Health Services Exhibit 7.4 Expenditures for U.S. Health Services, Select Years, Exhibit 7.5 Categories of Expenditures for U.S. Health Services, Exhibit 7.6 Distribution of Expenditures for Health Services Exhibit 7.7 Expenditures for Personal Health Services, Exhibit 7.8 Distribution of Expenditures for Personal Health Services, Select Years, , and Percentage of Total Expenditures Exhibit 7.9 Sources of Funds for Select Personal Health Services, Exhibit 7.10 Sources of Funds for Program Administration, Net Cost of Private Health Insurance, and Public Health, Reasons for Growth in Health Services Expenditures Exhibit 7.11 Estimated Contributions of Select Factors to Growth in Real Health Care Spending, Per Capita, Exhibit 7.12 Per Capita Expenditures for U.S. Health Services, Select Years, Exhibit 7.13 Percentage of U.S. GDP Directed to Health Services, Select Years Exhibit 7.14 Federal Aid to State and Local Governments, by Types of Aid, 1975, 1991,

14 xiv Contents Projections of U.S. Health Services Expenditures Efforts to Contain Health Services Costs and Expenditures Exhibit 7.15 CMS Projections of National Health Expenditures, Exhibit 7.16 Initiatives to Contain U.S. Health Services Expenditures Provider Payment Mechanisms Exhibit 7.17 Provider Payment Mechanisms Implications of Increasing Health Services Expenditures Exhibit 7.18 Growth in Healthcare Expenditures and Percent Distribution of Factors Affecting Growth, Part V Resource Production 8 The Health Services Workforce Physicians Exhibit 8.1 Physician Practice Settings, Exhibit 8.2 Physician to Population Ratios (Actual) and (Projected) Exhibit 8.3 Initiatives Intended to Affect the Supply of U.S. Physicians Issues Facing the U.S. Medical Profession Other Types of Health Services Providers Exhibit 8.4 Recommendations Regarding Physicians in the Workforce Mid-level Practitioners Exhibit 8.5 Health Professions Education, Supply, and Current Issues Exhibit 8.6 Active Health Services Personnel per 100,000 Population, Exhibit 8.7 Physician Assistant Practice Settings, Nurses Exhibit 8.8 Nurse Practice Settings, Pharmacists Exhibit 8.9 Numbers of Retail Prescription Drug Sales, Dentists Exhibit 8.10 Dentist Practice Settings, Health Services Administrators Complementary and Alternative Medicine Providers Exhibit 8.11 Frequencies of Adults Age 18 Years and Older Who Used Complementary and Alternative Medicine (CAM) Providers, by Type of Therapy, United States, 2002 and Hospitals Development of the Hospital in the U.S. System

15 Contents xv Exhibit 9.1 Types of Hospital Classifications The Hospital s Role in Today s Health Services System Exhibit 9.2 Number of U.S. Short-Stay Nonfederal Hospitals, Select Years, Exhibit 9.3 U.S. Short-Stay Hospitals by Governmental Status and Type of Ownership, Exhibit 9.4 U.S. Short-Stay Hospitals by Bed Size, Exhibit 9.5 Hospital Revenue Sources, Exhibit 9.6 Regulatory Programs for Hospitals Exhibit 9.7 Hospital Expenditures as a Percentage of Personal Health Care Expenditures (PHCE), Select Years, Hospitals in Transition Exhibit 9.8 Percentage of Hospitals with Insurance Products (in Managed Care), by Type of Product, Exhibit 9.9 Transition from Hospital to Health Services System Biomedical Research, Health Services Technology, and Technology Assessment Biomedical Research Exhibit 10.1 National Health Expenditures on Biomedical Research, Select Years, Exhibit 10.2 National Funding for Health Research and Development Exhibit 10.3 Congressional Appropriations for the NIH, Select Years, Health Services Technology Exhibit 10.4 Regulation of Food, Drugs, Cosmetics, and Devices Exhibit 10.5 FDA Approval Process for New Drugs Exhibit 10.6 National Health Expenditures (NHE) for Prescription Drugs, Select Years, Exhibit 10.7 Dimensions of Health Services Technology Assessment Technology Assessment The Role of Health Technology in a Changing Health Services System Part VI The Delivery System 11 Overview of the U.S. Health Services Delivery System Understanding the Delivery System: The Basis of System Reform The Continuum of Health Services in the U.S. System Exhibit 11.1 Continuum of Health Services How Health Services Are Delivered Exhibit 11.2 Delivery System Participants...311

16 xvi Contents Exhibit 11.3 Delivery System Participants, Person with Individual Policy or Self-Pay Exhibit 11.4 Delivery System Participants, Medicare Program Exhibit 11.5 Delivery System Participants, Medicaid Program Exhibit 11.6 Delivery System Participants, Government Health Programs Exhibit 11.7 Delivery System Participants, Uninsured Persons Exhibit 11.8 Delivery System Participants, Managed Care, External Utilization Review/Control Exhibit 11.9 Delivery System Participants, Managed Care, Internal Utilization Review/Control Exhibit Delivery System Participants, Managed Care, Self-Insured Employer Exhibit Consumer-Directed Health Plan Quality of Care Health Promotion and Disease Prevention Health Promotion Exhibit 12.1 Healthy People 2010 Focus Areas Exhibit 12.2 Effective Clinical Preventive Services Health Protection Disease Prevention: Primary, Secondary, and Tertiary Health Promotion, Health Protection, and Disease Prevention Issues in the U.S. Health Services Primary Care Defining Primary Care Primary Care Providers Access and Utilization of Primary Care Exhibit 13.1 Visits to Primary Care Generalist and Specialist Physicians, by Age Group, Exhibit 13.2 Number of Annual per Person Visits to Primary Care Providers, Exhibit 13.3 Number of Annual Visits to Physicians, by Age and Gender, Exhibit 13.4 Dental Visits in the Past Year, by Gender, Primary Care Issues in the U.S. Health Services System Exhibit 13.5 Annual Number of Physician Visits, by Age and Race/Ethnicity, Exhibit 13.6 Dental Visits in the Past Year, by Race/ Ethnicity and Age, Secondary Care What is Secondary Care?...339

17 Contents xvii Exhibit 14.1 Percentage of Persons with Any Activity Limitations, Who Provides Secondary Care? Exhibit 14.2 Visits to Primary Care Generalist and Specialist Physicians, by Type of Physician, Exhibit 14.3 Ambulatory Care Visits, Access to Secondary Care Exhibit 14.4 Projected Number of Persons with Chronic Diseases and Projected Expenditures for Their Care, Select Years, Utilization of Secondary Services Exhibit 14.5 Discharges, Days of Care, Average Length of Stay (ALOS), Nonfederal Short-Stay U.S. Hospitals, Select Years, Exhibit 14.6 Discharges, by Gender, Nonfederal Short-Stay U.S. Hospitals, Select Years, Policy Issues Related to Secondary Care Exhibit 14.7 Average Length of Stay, Nonfederal Short-Stay U.S. Hospitals, Select Years, Long-Term Care Defining Long-Term Care Exhibit 15.1 Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) Individuals and Populations Requiring LTC Services Exhibit 15.2 Limitation of Activity Caused by Chronic Conditions, by Age Group and Gender, Long-Term Care Providers Exhibit 15.3 Residence of People Needing Long-Term Care, Before Admission to a Nursing Home, by Payment Source, Exhibit 15.4 Examples of Services Available Under Medicaid Home- and Community-Based Services Waivers Exhibit 15.5 Medicare Skilled Nursing Facilities, RUG-III Classification System Exhibit 15.6 Percentage Distribution of Nursing Home Size, Select Years, Exhibit 15.7 Proportion of Residents in Nursing Homes, by Nursing Home Number of Beds, Exhibit 15.8 Percentage Distribution of Nursing Home Ownership, Select Years, Exhibit 15.9 Number of Intermediate Care Facilities for the Mentally Retarded, Select Years, Exhibit Medicaid Intermediate Care Facilities for the Mentally Retarded (ICFMR) Enrollees and Payments, Select Years Utilization of LTC Services...369

18 xviii Contents Exhibit Distribution of Types of Medicare Home Health Care Visits, Exhibit Medicare Beneficiaries Receiving Home Health Care Exhibit Medicare Home Health Care, Select Years, Exhibit Number of Medicaid Enrollees, by Category Served by Home Health Care, Select Years Exhibit U.S. Nursing Home and Related Care Facilities, Select Years, Exhibit Demographics of Medicare Beneficiaries in Skilled Nursing Facilities, Admissions per 1,000 Beneficiaries, Exhibit Number of Medicare Enrollees, by Category, Served by Nursing Facilities, Select Years, LTC Financing Exhibit Financing of Long-Term Care Services, Select Years Policy Issues Surrounding LTC Tertiary Care Defining Specialty Medical Care Specialty Care Providers The AHC as a Provider of Tertiary Care Policy Issues Facing AHCs Palliative Care Defining Hospice Care Hospice Care Providers Exhibit 17.1 U.S. Hospice Ownership, Exhibit 17.2 Hospice Organizational Status, Utilization of Hospice Care Exhibit 17.3 Sources of Payment for Hospice Care, Exhibit 17.4 U.S. Hospice Patients, by Primary Admission Diagnosis, Exhibit 17.5 U.S. Hospice Patients Exhibit 17.6 U.S. Hospice Patients, by Age Group, Policy Issues Surrounding Palliative Care The Care of Special Populations and Special Disorders Defining Mental Illness Exhibit 18.1 Admissions to Mental Health Organizations, per 100,000 Civilian Population, by Type of Service and Organization, Exhibit 18.2 National Health Expenditures for Mental Health Services and Percentage Distribution, by Type of Expenditure,

19 Contents xix Mental Illness Care Providers Exhibit 18.3 Serious Psychological Distress Among Persons Aged 18 Years and Older, Exhibit 18.4 Number of Mental Health Treatment Facilities and Beds for 24-Hour Residence and Treatment, Utilization of Treatment Services Exhibit 18.5 Comparison of Disability Programs Funded by the Social Security Act (SSA) Exhibit 18.6 Additions to Mental Health Facilities, Expenditures for Mental Health Services Exhibit 18.7 National Health Expenditures for Mental Health Services and Percent Distribution by Type of Expenditures, Policy Issues Related to the Care of People with Mental Illness Exhibit 18.8 State Mental Health Agency per Capita Expenditures for Mental Health Services, Select Years, The Health Services Delivery System: How Managed Care Has Influenced Delivery Definitions of Managed Care The Shift from Fee-for-Service to Managed Care in the U.S. Delivery System Models of Managed Care Strengths and Weaknesses of Managed Care Managed Competition Managed Care Market Share Exhibit 19.1 Enrollment in Employer-Sponsored Health Plans, 1996 and Exhibit 19.2 Number and Percentage of Medicaid Beneficiaries Enrolled in Managed Care, Policy Issues Surrounding Managed Care Appendix 19.1: Managed Care Models Part VII Measuring Outcomes of the Delivery System 20 Issues in Quality of Care Quality of Care: Working Definitions Development of a Quality Focus in the U.S. System Major Quality-of-Care Initiatives Measuring Quality of Care Monitoring and Regulating Quality of Care Exhibit 20.1 Summary of 2008 HEDIS Measures and Product Lines Quality of Care Policy Issues Exhibit 20.2 Concerns About Quality of Care Related to Cost Containment Initiatives

20 xx Contents Appendix 20.1: AHRQ-Sponsored Clinical Practice Guidelines List of Topics Epilogue What Have You Learned That Will Help You Analyze Proposed Changes? Who Supports Change, and Who Wants to Retain the Status Quo? Will Changes to the Health Services System Likely Be Sweeping or Incremental? What are Some Likely Consequences of Proposed Changes? Glossary of Key Words Bibliography Index About the Author

21 LIST OF ACRONYMS AND ABBREVIATIONS AAPCC adjusted average per capita cost ACF Administration for Children and Families ACHE American College of Healthcare Executives ACS American Cancer Society ACS American College of Surgeons ADA Americans with Disabilities Act of 1990 ADL activities of daily living AFDC Aid to Families with Dependent Children AHA American Heart Association AHA American Hospital Association AHC academic health center AHCPR Agency for Health Care Policy and Research AHP Association Health Plan AHRQ Agency for Healthcare Research and Quality AIDS acquired immunodeficiency syndrome ALA American Lung Association ALOS average length of stay AMA American Medical Association AOA Administration on Aging APA Administrative Procedures Act APACHE Acute Physiological and Chronic Health Evaluation APHA American Public Health Association APN advanced practice nurse ARRA American Recovery and Reinvestment Act ASPH Association of Schools of Public Health ATSDR Agency for Toxic Substances and Disease Registry BBA BHO BIA BIPA Balanced Budget Act behavioral health organization Bureau of Indian Affairs Benefits Improvement and Protection Act xxi

22 xxii List of Acronyms and Abbreviations BLA CABG CAH CAHPS CAM CBO CCMC CDC CDHP CER CFR CHAMPUS CHP CMS CNA COBRA COGME CON COPD CPOE CQI CRO CSI CT DALY DEA DEFRA DGME DHEW DHS DME DOD DOJ DRG DSH EACH EAP ECFMG biologics license application coronary artery bypass graft critical access hospital Consumer Assessment of Healthcare Providers and Systems complementary and alternative medicine Congressional Budget Office Committee on the Costs of Medical Care Centers for Disease Control and Prevention consumer-directed health plan comparative effectiveness research Code of Federal Regulations Civilian Health & Medical Program of the Uniformed Services Comprehensive Health Planning Act Centers for Medicare & Medicaid Services certified nursing assistant Consolidated Omnibus Budget Reconciliation Act Council on Graduate Medical Education certificate of need chronic obstructive pulmonary disease computerized physician order entry continuous quality improvement contract research organization computerized severity index computed tomography (scanner) disability-adjusted life year Drug Enforcement Agency Deficit Reduction Act direct graduate medical education (payment) U.S. Department of Health, Education, and Welfare U.S. Department of Homeland Security durable medical equipment U.S. Department of Defense U.S. Department of Justice diagnosis-related group disproportionate share hospital essential access community hospital employee assistance program Educational Commission for Foreign Medical Graduates

23 List of Acronyms and Abbreviations xxiii EMCRO EMIC EMR EMTALA EPA EPO EPR ERISA ESP ESRD EU FDA FDCA FEHBP FFS FMG FPL FSA FTE GDP GME GMENAC GNP Experimental Medical Care Review Organization Emergency Maternal and Infant Child Care Program electronic medical record Emergency Medical Treatment and Active Labor Act Environmental Protection Agency exclusive provider organization electronic patient record Employee Retirement Income Security Act Economic Stabilization Program end-stage renal disease European Union Food and Drug Administration Food, Drug, and Cosmetic Act Federal Employee Health Benefits Program fee for service foreign medical graduate federal poverty level flexible savings arrangement full-time equivalent gross domestic product graduate medical education Graduate Medical Education National Advisory Committee gross national product HCBS home- and community-based service HCFA Health Care Financing Administration HEDIS Health Plan Employer Data and Information Set HHS U.S. Department of Health and Human Services HI Hospital Insurance (Medicare Part A) HIAA Health Insurance Association of America HIE Health Insurance Experiment (RAND) HIPAA Health Insurance Portability and Accountability Act of 1996 HIPC health insurance purchasing cooperative HIV human immunodeficiency virus HMO health maintenance organization HPSA health professional shortage area HRA health reimbursement arrangement HRSA Health Resources and Services Administration HSA health savings account

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